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HousecallsUnderwriting Case Studies & Insights

Inside this issue

June 2016

Our Casebook

Case #1 – Preterm Delivery ............................................. Pg. 2

Case #2 – Sudden Coronary Artery Dissection .................. Pg. 5

Underwriting Puzzler ...................................................... Pg. 8

By Richard Braun, MDVice President & Chief Medical Officerrbraun@scor.com

Welcome to this issue of Housecalls, where we present challenging cases and provide relevant research on the morbidity and mortality associated with less common medical conditions or rare insurance underwriting situations. In this issue we discuss a case of a preterm infant. Unfortunately, preterm birth is not uncommon, but it does not come up often in life underwriting.

According to the World Health Organization, an estimated 15 million babies are born worldwide prior to 37 weeks’ gestation every year. That represents slightly more than 10% of live births. And, slightly less than 1 million babies die yearly due to complications of early delivery. Worldwide, the leading cause of children dying under the age of five is preterm birth complications. India, China and Nigeria had the highest absolute numbers of preterm births, and the United States had over a half million in 2013.

For the preterm infants who do not die, many are facing a lifetime of learning disabilities and/or hearing or visual impairments. It is also estimated that proper prenatal, perinatal and postnatal care could save more than 75% of premature babies. For the World Health Organization’s suggestions for improving the outcomes of preterm babies we refer you to their website: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/preterm-birth-guideline/en/

Dr. Regina Rosace recently joined the Medical Staff of SCOR Global Life in the Americas and will be discussing a case of preterm birth in this issue. Dr. Rosace recently served as Assistant Professor, Pediatrics, Case Western Reserve University Faculty Pediatric Emergency Medicine, Rainbow Babies

and Children’s Hospital in Cleveland, Ohio. She also served as Medical Director for First Catholic Slovak Ladies Association in Beachwood, Ohio. She is certified by the American Board of Pediatrics and is working towards Board Certification in Insurance Medicine. She currently serves on the Professional & Public Relations committee of the American Academy of Insurance Medicine.

Dr. Rooney returns in this issue with a case of coronary artery dissection (which can be associated with pregnancy and delivery) and another ECG Puzzler.

EditorsContentRichard Braun, MD913.901.4749rbraun@scor.com

CopyPam Granzin704.344.2725pgranzin@scor.com

By Richard Braun, MD

Dr. Braun is Vice President & Chief Medical Officer for SCOR Global Life in the Americas. He received a Bachelor of Science degree from the Towson State University (1975) and earned his medical degree from the University of Maryland (1979). Dr. Braun is board certified in Internal Medicine, Insurance Medicine and is a past President of the American Academy of Insurance Medicine.

Housecalls – June 2016 – 2

A family is applying for life insurance for their nine-month-old infant. The applied for amount, while high, appears consistent with siblings’. The infant was born at 35 6/7 weeks, weight was 50th percentile for his gestation, was given surfactant at birth and stayed in the NICU for 10 days. He made all of his well child checks and received all of his immunizations on time.

His older sibling and his father have asthma. His weight and height at six months are at the 75th percentile, not correcting for prematurity. He was born in early fall, and has had two episodes of bronchiolitis, both responsive to albuterol. There was a 23-hour observation in the emergency room at two months of age with no oxygen given. Later that winter he was seen and released for a second episode of bronchiolitis. On both visits, the APS listed runny nose, cough and cold symptoms, some wheezing and no respiratory distress or retractions. He followed up with his pediatrician in the days following each presentation and was improving. He has met all of his developmental milestones, and no other concerns are listed in the APS.

QuestionWhat are the mortality concerns of a premature infant?

AnswerLet us first review some of the definitions of prematurity. Prematurity is defined as any birth before 37 weeks gestation, as calculated from the mother’s last menstrual period. Late preterm is defined as 34 weeks to 36 6/7 weeks gestation. Very preterm is a gestational age of less than 32 weeks, while extremely preterm is less than 28 weeks gestation.

Many authors use weight criteria when classifying more preterm infants. Low birth weight (LBW) is less than 2500 gm, very low birth weight (VLBW) is

defined as less than 1500 gm, while extremely low birth weight (ELBW) is defined as less than 1000 gm.

Neonatal mortality rate is defined as death in the first 30 days of life, while infant mortality measures death in the first year of life.

According to the CDC, the premature birth rate in the US in 2014 was 9.6%. The rate has fluctuated a bit in recent years due to improvements in care, survival of ELBW infants which in the past would have perished and changes in obstetric practices involving scheduled Cesarean sections and induced deliveries. About one half of preterm births are the result of spontaneous preterm labor, the cause of which is unknown. Other factors precipitating early labor include but are not limited to pregnancy with multiples, infection, drug, alcohol or tobacco use, chronic health problems in the mother, pre-eclampsia, problems with the uterus or cervix and extremes in maternal age.

Most preterm infants do well (80% of late preterms survive without morbidity), but both mortality and morbidity increase with increasing prematurity. Even among term infants, mortality varies by increasing gestational age, early term infants have a higher mortality rate than late term infants (Figure 1).

Associated long term morbidities can include, intellectual disabilities and behavior problems, cerebral palsy, respiratory problems, visual problems including retinopathy of prematurity, hearing loss and feeding and digestive issues. All of these issues are not necessarily a result of prematurity but are definitely associated with it. From a mortality standpoint, most of the mortality occurs in the first month, although there still is an increased mortality rate in the first year compared to term infants.

In a study published in 2007, birth and death certificates of infants born in Utah between 1999 and 2004 were reviewed. Early neonatal (days 1-7), neonatal and infant mortality were calculated for each

Case #1Preterm Delivery

By Regina Rosace, MD, FAAFP Assistant Vice President, Medical Director

Fellow of the American Academy of Pediatrics, Assistant Professor at Case Western Reserve School of Medicine and Rainbow Babies and Childrens’ Hospital, working towards Diplomate of the American Academy of Insurance Medicine

Housecalls – June 2016 – 3

estimated gestational age (EGA) cohort.

Two separate calculations were performed, the first including all deaths and the second including infants whose listed cause of death was something other than birth defects. The term “birth defects” would encompass structural or biochemical abnormalities, including hereditary conditions such as chromosomal abnormalities, congenital heart disease, disorders of the central nervous system, etc. The Risk Ratios for all-cause mortality during the first year of life for those without birth defects are detailed in Figure 1. Important information such as maternal age and health, birth weight and cause of early delivery were not included in this analysis.

An older study of births in Norway between the years 1967-88 also provides an estimate of the mortality associated with prematurity. The relative risk of mortality was adjusted for year of birth, maternal age, and maternal education (Figure 2). Congenital anomalies were not considered as a factor.

Late preterm infants are the fastest growing subset of neonates. In the US in 2006, late preterms (LP) accounted for approximately 74% of all preterm infants. There is a threefold higher infant mortality rate in LP compared to their term counterparts (7.7 vs. 2.5 per 1000 live births). Congenital anomalies account for some of this increased mortality (Figure 3). LP infants are twice as likely to have a congenital malformation as term infants, and they are four times more likely than term infants to die of them.

Intrauterine growth retardation (IUGR), itself a cause of increased mortality, is more common among LPs. When accounting for SGA (small for gestational age) in LPs, there still is an increased mortality rate. Maternal placental and postnatal complications are also more common in LP vs. term infants. These are examples of causes of the prematurity, rather than the results of such.

Bronchiolitis is a very common illness typically caused by a viral infection that begins in the upper respiratory tract and involves the bronchiolar epithelial cells causing inflammation and mucus production. Usually managed in an outpatient setting, it is more prevalent during the winter months and can occur more than once in a single respiratory season.

Although essentially all children have antibody evidence of bronchiolitis by their third birthdays, this usually mild illness can become serious. Risk factors for severe disease include: prematurity, age less than 12 weeks, chronic pulmonary disease, congenital heart disease, immunodeficiency and neurologic disease. Severe disease would be manifested by respiratory distress, hypoxia and possibly respiratory failure.

From 1915 to 2008, infant mortality rates went from 99.9 deaths to 6.6 deaths per 1000 live births. Similarly, neonatal mortality rates from 1950-2008 decreased from 20.5 deaths to 4.3 deaths per 1000 live births. Other countries’ rates have continued to decrease, but the US (and Canada) have essentially plateaued, leading to worse ranking.

Between 2000 and 2005, preterm births increased by 9% which accounted for a large portion of deaths. Low birthweight infants rose from 1983-2005, 6.8% to 8.2%. Canada saw a similar rise in ELBW

Gestational Age (wks)

Relative Risk of Mortality (Females)

95% Confidence Interval

22-27 9.7 4.0-23.7

28-32 1.8 .93-3.5

33-36 1.6 1.2-2.0

37-42 1 (Reference) ---

>42 1.2 0.32-1.6

Figure 2 – Relative Risk of Death between Ages 1-5.9 Years based on Gestational Age at Delivery

Swamy et al

Gestational Age (wks)

Risk Ratios 95% Confidence Interval

34 4.62 2.5-8.4

35 3.91 2.3-6.5

36 3.14 2.0-4.9

37 1.81 1.2-2.8

38 1.75 1.2-2.5

39 1.02 0.7-1.5

40 --- ---

41 1.13 .6-2.1

42 3.42 1.1-10.4

Figure 1 – Mortality Risk Ratios for Death between Days 1-365 after Birth by Gestational Age (Excluding Known Birth Defects)

Young et al

Housecalls – June 2016 – 4

Preterm Delivery (cont.)

infants. It appears that the lack of decline and/or slow improvement in infant and neonatal mortality rates has to do with the increasing number of live births of the very small and premature.

Returning to the caseThis child is a late preterm infant who at nine months of age appears to be growing and developing normally. His weight is within the average range without correcting for prematurity. He received surfactant at birth, which is used as prevention or treatment of respiratory distress syndrome (policies regarding administration vary between institutions). He was discharged from his neonatal stay on no medications.

He did present on two separate occasions with symptoms of bronchiolitis including cough, runny nose and wheezing but no retractions or respiratory distress. Given that our proposed insured was a late preterm infant and only two months of age during his first episode, he was observed in the hospital to monitor his respiratory status. He ultimately was discharged home doing well and followed up the next day with his pediatrician. Although he was given albuterol and responded to it favorably, that is usually an indication of family history of asthma rather than severity of illness.

The majority of mortality with prematurity occurs in the first 30 days of life, often involves congenital

malformations, low birth weight and respiratory distress of the newborn among other things. Conditions that would be concerning for possible increased mortality would include congenital heart disease, neurologic issues -- especially those including developmental delay, an oxygen requirement or feeding difficulties, especially if listed as failure to thrive.

Our youngster seems to be growing well and weathering the normal childhood illnesses without difficulties. The case was assessed at minimal to no excess mortality.

ReferencesKugelman, A, Colin, A “Late Preterm Infants: Near Term but Still in a Critical Development Period”. Pediatrics 2013:132 (4): 741-751.

Lau, C, et al “Extremely Low Birth Weight and Infant Mortality Rates in the United States”. Pediatrics 2013:131 (5): 855-860.

http://www.statisticbrain.com/premature-birth-statistics/ accessed 5/11/2016.

Young, P, et al “Mortality of Late Preterm (Near-Term) Newborns in Utah”. Pediatrics 2007:119 (3): 659-665.

Swamy K et al. “Association of Preterm Birth With Long-term Survival, Reproduction, and Next-Generation Preterm Birth”. JAMA. 2008;299(12):1429-1436.

EGA wk

Birth Defects

Immaturity Asphyxia Infections Known causes(endo, neuro,

etc)

SIDS Accidents All others

Total #

34 70 5 10 0 2.5 2.5 0 10 40

35 64 14 2 0 6 10 0 10 50

36 60 6.5 6.5 1.3 6.5 9.1 1.3 9.1 77

37 57 3.4 2.3 4.5 9.1 11.4 5.7 6.8 88

38 42 2.7 6 4.7 7.4 19.5 4.7 13.4 149

39 43 2.1 7.7 7 4.9 21 5.6 8.4 143

40 33 2.8 8.3 15.3 4.2 11.1 11.1 13.9 72

41 48 4 0 12 4 16 8 8 25

42 57 0 0 14.3 0 0 14.3 14.3 7

Figure 3, EGA – Estimated Gestational Age Causes of Death for Each Gestational Age Cohort in the First Year by %

Young et al

UpToDateR last accessed 5/11/2016.

Housecalls – June 2016 – 5

A 35-year-old female applies for life insurance. Five years prior to the application and one week postpartum, she was diagnosed with a spontaneous dissection of the proximal portion of the left circumflex coronary artery. Medical management was attempted, but because of ongoing severe angina she underwent coronary artery bypass graft surgery. Angiogram at that time showed no significant atherosclerotic disease.

She has not had any further pregnancies but is considering a future pregnancy. She has had no further chest pains or any other significant cardiac problems. She is followed by cardiology regularly and has had a normal stress test and echo within the last year, both done to evaluate atypical chest pain.

Family history is negative for cardiac conditions. Her medical history is positive for medically controlled hyperlipidemia but is otherwise unremarkable. There is no history of tobacco use, past or present. No imaging studies of other arterial systems were included in the records. Her current ECG is normal.

Question What are the mortality concerns after a spontaneous dissection of a coronary artery?

AnswerSpontaneous dissection of a coronary artery (SCAD) is uncommon and is defined as dissection that is non-traumatic and non-iatrogenic. First reported in 1931, most of the early cases were diagnosed at the time of an autopsy.

This condition has historically been associated with coronary artery disease in young women. With the markedly improved imaging techniques currently

used, many feel this condition is more prevalent than previously thought, and might be involved in as many as 24% of myocardial infarctions in women <50 years of age. Some believe the condition is not uncommon in older age men and women as well. And the older the patient, the more likely that the dissection is related to atherosclerosis.

During SCAD separation of the coronary arterial walls results in the creation of a false lumen producing an intramural hematoma which leads to narrowing of the true lumen and decreased coronary blood flow (Figure 1). Severe angina, myocardial infarction or sudden death can occur. SCAD can be associated with underlying atherosclerosis, but it is also found in young individuals with no obvious atherosclerosis. In older men presenting with SCAD, atherosclerosis is not uncommon.

Although up to 20% of cases are considered idiopathic the remaining 80% are associated with a predisposing arterial disease. Fibromuscular dysplasia (FMD) is the associated disorder in the vast majority of cases, but other associated conditions include postpartum state,

Case #2Sudden Coronary Artery Dissection

Figure 1 – Traumatic Coronary Artery Dissection

Coronary artery with an intramural hematoma

By William Rooney, MD, FAAFP, EMBA Vice President, Medical Director

Dr. William (Bill) Rooney is Vice President, Medical Director at SCOR Global Life in the Americas. Dr. Rooney’s responsibilities include facultative case review work, researching and updating SOLEM®, researching and writing articles for a variety of SCOR publications

and more. He earned a medical degree from the University of Missouri – KC (1981) & an Executive Master’s in Business Administration from Benedictine College in Atchison, Kansas (2009). He is board certified in Family Medicine with the American Board of Family Medicine.

Housecalls – June 2016 – 6

multiparity (>four births), connective tissue disorders (e.g. Marfan’s syndrome, Ehlers-Danlos type IV), systemic inflammatory conditions (e.g. systemic lupus erythematosus, Crohn’s disease), extreme emotional stress and hormonal therapy.

It is not uncommon for an affected individual to report a precipitating stressor such as forceful emesis, intense exercise, labor and delivery or recreational drug usage. Most series have a preponderance of younger women developing SCAD in the peri-partum period. It is known that the hormonal changes of pregnancy cause changes in the vascular wall including smooth muscle proliferation, impaired collagen synthesis and changes to the molecular makeup of the media layer. These changes combined with the increased blood volume and cardiac output may lead to increased shearing forces during the stress of labor and delivery. Underlying arterial disease processes as discussed above may exacerbate these stresses.

The clinical presentation of this condition is typically that of a myocardial infarction. Chest pain, dyspnea, diaphoresis, syncope and nausea are common complaints. The condition can present with cardiac arrest. ST-elevation MI (STEMI) or non-ST elevation MI have both been seen. The most frequently involved artery is the left anterior descending (LAD), but involvement of any of the coronary arteries, including the left main stem, has been documented.

The diagnosis of SCAD is most commonly made by coronary angiogram, or at the time of autopsy. Intracoronary imaging with intravascular ultrasound can also be used to make the diagnosis. Diagnosis by cardiac CT angiography (CCTA) has been disappointing thus far, but it has been used successfully for serial monitoring of disease activity.

Treatment consists typically of either conservative management, percutaneous coronary intervention or coronary artery bypass grafting. Thrombolytic therapy

is typically not advocated. The natural history of the disorder, based upon follow up angiography, appears to be spontaneous healing in the vast majority of cases.

Long term prognosis is reported as variable. Approximately 80% of the time there is an underlying arterial disorder, most commonly fibromuscular dysplasia, and the underlying condition can create issues with recurrence of coronary artery disease or arterial disease in another location, such as the renal or carotid arteries.

One recent study in Vancouver showed a two-year major adverse cardiac event-rate of 10.4 to 16.9%, with recurrent dissection rate of 13.1%. In another study from the Mayo Clinic, the recurrent dissection rate was 17%.

Regarding mortality, case reports or small series of patients were reported on initially and mortality was high. More recent publications have shown a somewhat improved mortality picture (Figure 2).

In one study, involving 87 patients (mean age 42.6 years), the 10-year data suggested there was a 47% chance of subsequent death, congestive heart failure, myocardial infarction or repeat dissection. In other studies, it has been reported that the subgroup of patients with postpartum SCAD have a worse prognosis. They have been reported to have larger infarcts, more proximal artery dissections, and worse post-event ejection fractions.

There is a need for prospective studies to help elucidate the mortality of this condition. Interestingly, there are at least two ongoing prospective studies which might give great information regarding long

Sudden Coronary Artery Dissection (cont.)

Figure 2 – Mortality Concerns with Sudden Coronary Artery Dissection

In-hospital Varies from 0-5%

One-year Varies from 1-4%

Ten-year Up to 7.7%

Study Start Date

Anticipated Completion

Date

The “Virtual” Multicenter SCAD Registry (Supported by Mayo Clinic)

July 2011 December 2017

The Canadian SCAD Cohort Study

June 2014 December 2019

Figure 3 – Current Studies

Housecalls – June 2016 – 7

term prognosis (Figure 3). We will watch these studies carefully and plan on commenting on the results in a future publication.

Returning to the caseThis is a case of SCAD in a postpartum woman. Unfortunately, we don’t have information regarding any other underlying etiologies for the SCAD other than the postpartum state.

SCAD in the postpartum period in particular has been reported to have an unfavorable prognosis. The high rate of recurrence after SCAD as well as the association with other vascular problems is problematic. Finally, the high rate of complications, recurrences, and mortality currently being quoted in the literature makes this case appear to have significant long term mortality concerns.

Referenceshttps://clinicaltrials.gov/ct2/show/NCT01429727?term=spontaneous+coronary+artery+dissection&rank=1 accessed 2/4/2016.

https://clinicaltrials.gov/ct2/show/NCT02188069 accessed 2/4/2016.

Yip, A, Saw, J “Spontaneous coronary artery dissection—A review”. Cardiovascular Diagnosis and Therapy 2015;5(1): 37-48.

UpToDateR last accessed 2/4/2016.

Pretty, H. “Dissecting aneurysm of coronary artery in a woman aged 42”. BMJ 1931;1:667.

DeMaio SJ Jr. et al. “Clinical course and long-term prognosis of spontaneous coronary artery dissection”. Am J. Cardiol 1989;64-471-474.

Ito, H et al. “Presentation and therapy of spontaneous coronary artery dissection and comparisons of postpartum versus non-postpartum cases”. Am J Cardiol 2011; 107:1590-6.

Tweet MS et al. “Clinical features, management, and prognosis of spontaneous coronary artery dissection”. Circulation 2012; 126:579-88.

The information conveyed and the views expressed in this newsletter are provided for informational purposes only and are based on opinions and interpretations made by SCOR Global Life Americas (formerly SCOR Global Life US Re Insurance Company). The opinions and interpretations expressed by SCOR Global Life Americas may not be the only interpretation available. This publication should not be copied or shared with any other company, reinsurer or consultant without obtaining prior approval from SCOR Global Life Americas.

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Underwriting Puzzler...By William Rooney, MD, FAAFP, EMBA Vice President, Medical Director

In this issue of the Puzzler Dr. Rooney presents another EKG. What is the major abnormality presented in this EKG? To find the answer, be sure to visit the Housecalls page on www.scorgloballifeamericas.com. Click on the “June Puzzler” Powerpoint presentation to confirm your findings. ∞